Ch 22 surgical wound care

Phases of wound healing

Homeostasis

inflammatory phase

reconstruction phase

maturation phase

Inflammation stage of healing

coagulation

release of cytokines and growth factors

cell recruitment and chemotaxis

Phases of wound healing

Homeostasis

inflammatory phase

reconstruction phase

maturation phase

Inflammation stage of healing

coagulation

release of cytokines and growth factors

cell recruitment and chemotaxis

proliferation stage of healing

epidermal resurfacing

fibroplasia

angiogenesis

extracellular matrix synthesis

maturation stage of healing

exracellular matrix formation

scar tissue formation

wound closure

contraction

Complications of wound healing

impaired wound healing requires accurate observation and ongoing interventions

wound bleeding

wound infection

Process of wound healing

primary intention

secondary intention

tertiary intention

Dry dressings

may be chosen for management of a wound with little exudate/drainage

Wet-to-dry dressing

pirmary purpose is to mechanically debride a wound; as the dressing dries, it hadheres to the wound and debrides it when the dressing is removed

Transparent dressings

self-adhesive transparent film is a synthetic permeable membrane that acts as a temporary second skin

What is dehiscence

wound layers separate or open

When would dehiscence happen?

it may result after periods of sneezing, coughing, or vomiting

What should a patient do if there is dehiscence?

remain in bed and receive nothing by mouth, be told not to couch, and be reassured

Nursing interventions for dehiscence?

place a warm, moist sterile dressing over the area until the provider evaluates the site

Evisceration

abdominal organs protrude through an opened incision

What should patient do if there is evisceration?

remain in bed, and the wound and contents should be covered with warm, sterile saline dressings

When should the surgeon be notified with evisceration?

immediately

How is evisceration repaired?

surgery, this is a medical emergency

When are staples and sutures generally removed?

within 7 to 10 days after surgery, or sooner if healing is adequate

Who orders the removal of sutures or staples?

the medical provider

Removal of sutures and staples

removed one at a time or removal of every other suture or staple

What are sutures and staples replaced by?

steri-strip as the frist phase, with the remainder removed in the second phase

Exudate and drainage

serous

sanguineous

serosanguineous

If the tissue is infected what color would the exudate/drainage be?

may be brown-green purulent

Serous

clear or pale yellow, thin watery plasma; often normal during the inflammatory stage of wound healing

Serosanguineous

thin, watery, pale red to pink, mixed with plasma and RBCs

Purulent

thick, opaque, yellow, green, brown, or tan; often indicates infection

sanguineous

fresh blood, indicating new blood vessel growth or disruption

What do you assess with exudate and drainage?

color, amount, consistency, and odor

what do drains do?

drains fluid from surgical site

Jackson pratt: JP drain

100 mL

Hemovac

400 mL

Constavac/Stryker

>400 mL

Penrose

no container

Wound irrigations

cleansing solution is introduced directly into the wound with a syringe, syringe and catheter, shower, or whirlpool

How is fluid retention avoided in wound irrigation?

positioning the patient on his or her side to encourage the flow of the irrigant away from the wound

How does wound irrigation promote healing?

by removing debris from a wound surface, decreasing bacterial counts, and loosening the removing eschar

What direction should you cleanse with wound irrigation?

from the least contaminated area to the most contaminated area

Wound vacuum-assisted closure

uses negative pressure to remove fluid from surrounding the wound

After a bandage is applied, the nurse should

assess, document, and immediately report changes in circulation, skin integrity, comfort level, and body function such as ventilation or movement

When can a nurse remove a bandage?

when there is an order from the medical provider

What patient teaching should the nurse provide for bandages and binders?

the bandage would feel relatively firm or tight

Nursing diagnoses

impaired skin integrity

imbalanced nutrition: more than body requirements

imbalanced nutrition: less than body requirements

ineffective tissue perfusion (specify type)